“The care package arranged for Melanie following discharge from lengthy in-patient…”
Dated 7 Mar 2022, from the coroner for Surrey. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 2 May 2022. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated7 Mar 2022
- Deadline2 May 2022
- Published on judiciary.uk16 Mar 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Surrey and Borders Partnership NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 2 May 2022. A reply may have been sent and not yet published. |
The coroner’s concerns
– 1. The care package arranged for Melanie following discharge from lengthy in-patient admission was not followed and was altered to something which the treating doctor did not consider adequate. 2. The walk book was not properly completed. 3. There was no extra planning for changes in circumstances: Melanie faced never being allowed to return to family life with her husband and son due to Child In Need proceedings; changes in medication and less support from family due to the Social Services requirements. 4. There was no missing person plan in place with timeframe and steps of escalation for Melanie’s leave. 5. Risk assessment prior to leave was not adequate. 6. Risk assessment prior to leave was not recorded.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2022-0079
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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